​I’ve had the dubious pleasure of dealing with various incidents and outbreaks over the years. They can be very stressful experiences for everyone concerned, but a clear methodical approach can go a long way to alleviating the levels of stress both in both you and your colleagues.
 
Imagine the scenario:
It’s 9am and the Senior Biomedical Scientist knocks on your door “ummm the laboratory has inadvertently processed a tissue sample containing Brucella melitensis on the open bench!”

“Can I notify a case of meningitis?” asked the sleepy sounding Junior Doctor.
 
“You notify Public Health England, not Microbiology” explained the Microbiologist.
 
“Damn, I thought I asked for PHE, sorry” said the Doctor. “Oh well, I‘ll call them in a moment. Can I ask you about the patient as well?”
 
“Sure”
 
“The patient is an eighteen year old student back from University for the holidays. They have a severe headache, neck stiffness and photophobia. We are about to do a lumbar puncture. Is there anything additional we should look for?”
 
“Don’t forget the protein and glucose, but have you thought of mumps? Has the patient been vaccinated?”
 
“Errrr….sorry I don’t know”
​

“Okay, get some more history and find out if they have had the MMR and are therefore vaccinated against mumps. See if they have any tender salivary glands, especially the parotid, and do still get that LP done. To begin with cover for bacterial meningitis anyway with Ceftriaxone and watch out for any signs of encephalitis such as confusion, reduced consciousness or seizures, oh and if you’ve been up most of the night…schedule in a coffee break, you won’t work any better on your last legs!”
 
“OK, thanks, I’ll get a cup while I’m on hold for the PHE!” said the junior and rang off.

Why do we vaccinate against mumps?
In the UK, prior to the introduction of MMR in 1988, 90% of adults had evidence of past infection with mumps. Mumps presents in various ways:
 

• The most common presentation with mumps is a 2 day flu-like illness followed by painful swelling of the salivary glands, usually the parotid gland in the cheek but occasionally the sublingual or submaxillary glands, as well as a fever. The swelling usually lasts 7-10 days.
• Most doctors are aware that 20-30% of post-pubertal males with mumps develop orchitis (inflammation of the testicles) which is usually unilateral, and 5% of post-pubertal women develop oophoritis (inflammation of the ovaries). Even though sterility is a very rare sequel the alarm and reflex wince caused by the thought of painful testicles or ovaries is probably why most doctors know about this form of mumps!
• Respiratory symptoms are common in mumps (40-50%) of cases, especially in children under 5 years old.
• A mild pancreatitis is present in 4% of patients with mumps.
• 20-25% of patients with mumps are asymptomatic.

 
Okay, so none of these presentations are particularly pleasant but they don’t really explain why a mumps vaccine is so important. The reason we vaccinate against mumps is because it used to be the most common cause of meningitis in the UK, not to mention it was a leading cause of hearing loss in children. Meningitis occurs in 10% of mumps cases but is usually self-limiting. So what, it’s self-limiting…. But added to this, encephalitis occurs in 1 in 6,000 patients with mumps. I know this doesn’t sound like much either but with a population of 65 million in the UK that meant the UK got about 10,000 cases per year…before we had the MMR vaccine. Some of these patients with mumps encephalitis develop long term complications too such as paralysis, seizures and hydrocephalus, oh… and 1% died.
 
In fact, prior to MMR, mumps was responsible for 1200 admissions to hospital and 100 deaths per year in the UK. And not only did mumps cause serious infections it was also responsible for many lost days of work as parents took time off to look after their children who were off from school. This is why we vaccinate against mumps! Remember we vaccinate for economic reasons too, not just the medical ones.
 
What is the current state of mumps in the UK?
Mumps, like all infections prevented by routine childhood vaccinations, is a notifiable disease in the UK. All suspected cases should be notified urgently to Public Health England (PHE).
 
It has been widely reported that measles, one of the other infections covered by MMR, is on the rise in the UK but what is going on with mumps?
 
Up until 2003 there had only been about 100-800 cases per year of mumps in the UK but since then as a result of falling vaccine coverage, the number of cases of mumps has climbed; with a large epidemic of over 40,000 cases in 2005. Rates have hovered around the 2000-4000 mark most years since, dropping to 1031 in 2018. In the first 3 months of 2019 there have already been 800 cases. In particular there have been a number of outbreaks in UK universities this year as the current students are part of the generation who grew up during the MMR scandal and therefore have not been vaccinated.

​How is mumps diagnosed?
Mumps is usually diagnosed by looking for virus by PCR on a buccal swab (a swashbuckle!?!)… No editor chief in charge!!!! The buccal swab is taken from inside the cheek around the outflow from the parotid duct after gently massaging the parotid gland (be gentle, this is uncomfortable!). In the UK the kit for taking a swashbuckle, I mean, a buccal swab is obtained from PHE who will post the kit directly to the patient or their relatives with clear instructions on what to do.

​As well as taking the swab it is a good idea to take acute serum to look for IgM. IgM is usually produced within 5 days of onset of symptoms so if the acute sample is negative it should be repeated after 5-10 days to confirm antibody production and hence infection.
 
PCR can also be performed on CSF when meningitis or encephalitis is suspected.
 
How is mumps treated?
There is no specific treatment for mumps, but supportive care with antipyretics and fluids may be required. Complications such as seizures may require specialist management e.g. by a Neurologist.
 
Infection control precautions
Mumps is highly infectious, spread by droplets from the respiratory tract. Patients are infectious from 2 days before the salivary gland inflammation occurs until 5 days after. The incubation period is usually 16-18 days (range 12-25 days).
 
Patients should have precautions in place during the infectious period and if at home self-isolation should be undertaken, however in hospital precautions are:

​So after speaking to the patients parents it turned out our patient hadn’t been vaccinated against mumps, they asked the obvious question parents ask, “is this our fault!?” The standard response for this type of enquiry is “as medical staff, we are non-judgemental”.
 
Our patient did indeed have tender parotid glands and his lumbar puncture showed a viral meningitis. The Junior Doctor notified PHE that this was probable mumps meningitis, which was later confirmed by PCR on the CSF. Fortunately our patient didn’t develop any symptoms or signs of encephalitis and soon made a full recovery. After his discharge from hospital he did go on to have his MMR vaccine as he and his parents were now worried as he was obviously also at risk of getting measles… Maybe our non-verbal communication skills weren’t so “non-judgemental!” Please vaccinate your kids; vaccines are exceptionally safe, but many viruses, bacteria and infections are not!

The Neurologist came to chat to the Microbiologist about a complex and puzzling patient. The patient had presented with back pain and acute retention of urine; she was also shown to have some weakness in her legs as well as brisk knee reflexes. The Neurologists had been convinced that she had some form of disc prolapse or some other lesion pressing on her spinal cord and so had done a scan of her back but this was completely normal.

​The Microbiologist asked where the patient had been born and after ringing the ward to find out the Neurologist reported that the patient had actually been born and spent her childhood in the Caribbean.

Five years ago The Daily Mail newspaper ran an article titled “Could you catch TB from YOUR tabby?” and of course as a Microbiologist and an owner of 5 cats, I had to blog on that!  However recently this subject has impacted my clinical work.

It was another dull and dreary afternoon giving advice when an excited Dermatologist phoned about a patient with funny skin lumps. (Microbiologists get excited about bugs, Dermatologists get excited about rashes, so lumps and bumps together… what can I say…we were very excited!!)
​
Their patient was a keen gardener who had been clearing a large number of blackthorn trees (good for making sloe gin) and despite wearing thick gloves had managed to get pricked and scratched all the way up their arms. At the site of one of those puncture wounds they had developed a small red lump which had eventually turned into a small ulcer. The ulcer hadn’t got much better and over the next few weeks the patient had noticed a number of other lumps appearing up their arm and then hard swellings in their armpit.

Both the patient and their family Doctor thought they might have an aggressive skin cancer which had spread to the lymph nodes but the Dermatologist thought this might be something else.
 
“I think this might be sporotrichosis” said the Dermatologist.
 
The Microbiologist nearly fell off his chair! What a great piece of clinical acumen he thought; this could indeed be sporotrichosis.
 
“How the heck did you think of that?” the Microbiologist asked.
 
“Oh, I’ve seen it before when I worked in Brazil for a while” answered the Dermatologist. “But I can’t remember how to diagnose it or treat it…!”
 
Crikey, thought the Microbiologist, not sure I would even have thought of it…
 
So what is sporotrichosis?
Sporotrichosis is a sub-acute or chronic infection caused by the fungus Sporothrix schenkii. Laboratories tend to identify S. schenkii but in fact there are actually a group of at least six different fungi, the most common of which is S. schenkii. Others in the group include S. brasiliensis, S. globosa, S. mexicana, S luriei and S. pallida. Sporotrichosis is very rare in the UK with only 1 case report in the literature since the year 2000.
 
Where do you find S. schenkii?
Sporothrix schenkii occurs Worldwide, and is found in organic matter such as sphagnum moss, hay, soil and other vegetation. Most cases of sporotrichosis have occurred in Brazil, USA, India, Japan and Mexico. It occurs in people who have occupational exposure to these sources of fungi such as gardeners, farmers, landscapers and even Christmas tree sales people! Infection can occur when the fungal spores are inoculated through the skin or when a wound is contaminated with organic material.
 
An outbreak of 84 cases of sporotrichosis, in Wisconsin in the USA, occurred due to contaminated sphagnum moss used to pack conifer seedlings. In South Africa in the 1960s there were over 3000 cases due to exposure to splinters from contaminated timber used in gold mining.
 
In Rio de Janiero, Brazil, there is a very large on-going outbreak of sporotrichosis due to S. brasiliensis, where more than 2,000 cases have occurred since 1988 spread from infected domestic cats. The cats have had a mixture of skin and respiratory infections, which has spread to their owners mainly via facial and mucus membrane involvement (another reason not to kiss your cat!).
 
There have also been a few cases of laboratory acquired sporotrichosis described in the literature where lab workers have caught the infection from handling either cultures of the mould form or infected animals.
 
How does sporotrichosis present?
Most cases of sporotrichosis are lymphocutaenous and follow inoculation of spores into soft tissue in patients who are otherwise fit and healthy. A papule (a small lump up to 1cm in diameter) forms within days to weeks at the original point of entry and eventually ulcerates, develops surrounding redness (erythema) and discharges clear colourless and odourless fluid. Over the next few weeks further skin lesions develop along the line of lymphatic drainage in a process known as “sporotrichoid spread” with enlargement of the associated lymph nodes. Without treatment the lesions will persist indefinitely with periods of improvement followed by flare-ups; even without treatment this form of infection is not fatal.
 
Sporotrichosis can also occur as an opportunistic infection in patients with other underlying illnesses:

• Pulmonary infection can occur in patients with chronic obstructive pulmonary disease (COPD) and presents in a similar fashion to tuberculosis with fever, night sweats, weight loss, worsening shortness of breath and ultimately death if untreated.
• Bone and joint (osteoarticular) infection can occur in alcoholics as a result of haematogenous spread (although rarely it can also occur via direct inoculation); bone destruction is progressive causing substantial deformity.
• Meningitis and disseminated infection can very rarely occur in profoundly immunosuppressed patients with HIV or lymphoma.

 
How is sporotrichosis diagnosed?
A history of exposure to potentially contaminated organic material is the key to making the diagnosis along with the typical pattern of cutaneous sporotrichoid spread.
 
The gold standard way of diagnosing sporotrichosis is to grow the fungus from tissue or body fluid. Sporothrix spp. are dimorphic fungi; they have two different growth characteristics depending on the temperature at which they are growing. At environmental temperatures around 25-30oC they grow as a filamentous mould whereas at body temperature they grow as a yeast. The mould takes 1-2 weeks to become apparent and then grows to form cream coloured colonies which eventually turn grey and produce the typical fluffy mycelia of a mould. The yeast form produces colonies which are cream coloured and wrinkled. Once the organism is growing in the mould form it can be identified from the microscopic appearance of its mycelia, conidia and spores.

Yeast forms of the fungus can sometimes be seen on histopathological examination of tissue, especially if using specific fungal stains, although they are not distinctive in appearance.
 
How is sporotrichosis treated?
The treatment of sporotrichosis depends on the type of infection.

• For lymphocutaenous infection the treatment of choice is PO Itraconazole 200mg OD until 4 weeks after all of the lesions have resolved (usually 3-6 months).
• For pulmonary, osteoarticular and disseminated sporotrichosis treatment should be started with IV liposomal Amphotericin B 3-5mg/kg OD and when the patient has shown sustained improvement they can be changed to PO Itraconazole 200mg BD for 12 months.
• Meningitis is treated with 4-6 weeks of IV liposomal Amphotericin B 3-5mg/kg OD before changing to PO Itraconazole 200mg BD for 12 months.

 
IV liposomal Amphotericin B is incredibly expensive; in the UK AmBisome costs £575 per day to treat a 70kg patient (and many of our patients weigh much more than this!). Alternatively patients may be given the more toxic but cheaper Amphotericin B deoxycholate (Fungizone) at 0.7-1mg/kg costing just £3.88 per day for a 70kg patient… but it is very nephrotoxic!
 
So our patient had a biopsy taken and yeast like fungi were seen on histological examination. Two weeks later a fluffy mould was growing on culture and the laboratory was able to confirm sporotrichosis. In the meantime the patient had been empirically treated with Itraconazole and got much better; they had also decided not to do any more gardening without better protection… although a good homemade sloe gin made from the fruit of the vicious blackthorn could possibly be worth the risk!!

A tried and tested sloe gin recipe (it’s very good but please drink responsibly!!)

• 1.2Kg cleaned and frosted or pricked sloes (Blackthorn berries)
• 120g granulated sugar (more if you want it sweeter)
• 1.6L gin (cheap as you like!)

Put all into a 3L Kilner jar and shake, shake daily for 1 week then once a week for 3 months. Drain the sloes but keep the juice! Bottle (use the empty gin bottles) and leave as long as you can, minimum 3 months but the longer you leave it the better the sloe gin... try 18 months, that makes a great sloe gin.

Last weekend the Nuts & Bolts team (except cats!) went to the cinema to watch the new film about the early life of J.R.R Tolkien. I have been a fan of Tolkien since reading The Hobbit at the age of 5 years old and The Lord of the Rings when I was 6… okay this is early to read this book; I didn’t understand much of the dark bits but I was captured by the heroic story and have read it again many times since… the ECIC cannot understand this, she thinks it’s weird to read a book when you already know how it’s going to end… maybe she’s right, but that won’t stop me, where did I leave my copy, or my second copy or that third copy or…
​ 
Surely you can’t connect Tolkien with microbiology!? Read on to find out more…

​Tolkien enlisted in the Lancashire Fusiliers and was sent to the Western Front in June 1916 to join the Somme offensive. He was assigned as a Lieutenant in the signal corps and put in charge of enlisted men; there is a great quote from him, "the most improper job of any man... is bossing other men, …not one in a million is fit for it, and least of all those who seek the opportunity”… a sentiment I share.

“We have a young child with a fever and a rash who isn’t very well and we want to test for measles” said the Junior Doctor working in Paediatrics.
 
“Have they been vaccinated?” asked the Microbiologist in reply.
 
“No, their Mum was worried about the vaccine and so they haven’t had it done” was the response.
 
“Do they have any spots in their mouth?” asked the Microbiologist.
 
“They don’t have any spots, it’s not Chicken Pox it’s more like measles…” replied the Doctor sounding confused.
 
“They’re called Koplik spots, maybe get a Consultant to have a look. Is the child isolated?”
 
“Errrmmmm…” replied the Doctor “I don’t think so…”
​

The patient is a young female who presented with a very high fever of 40.5oC, lethargy and not eating. The past medical history included dislocated knees due to a congenital problem requiring surgery to relocate and reconstruct the patella groove. She is not taking any regular medication, has not been in contact with anyone else who is unwell and has not travelled out of the UK.
​
Essentially this is a case of pyrexia of unknown origin or PUO. What is PUO and what should you do about it?

“I think my patient has syphilis” said the GP.
 
“Why do you think that?” asked the Microbiologist.
 
“Well, they have a funny skin lump and I had read recently that syphilis can mimic any other type of infection and that it’s making a comeback and so I did the test and it’s positive!”
 
The Microbiologist groaned to himself.
 
“Let me have a look at the results as well” he said.
 
To the Microbiologists surprise the patient did have positive syphilis serology.

“Where is the patient from?” the Microbiologist asked.
 
“What do you mean? They live locally” answered the GP.
 
“I mean where were they born? Have they lived abroad?”
 
“Oh, I don’t know. Why does it matter?”
 
“Can you give them a call and find out then call me back. This could be Yaws, Pinta or Bejel” replied the Microbiologist.
 
“Sorry my what? …Your's a pint of what…and a bagel? What did you say? This line is really bad” said the GP getting increasingly confused.
 
“Find out where they have been and call me back and then I’ll explain further” answered the Microbiologist.

The mother was frantic.
 
“I don’t know what happened” she cried to the Paediatrician, “he was just a bit irritable when I put him to sleep last night and had a bit of redness around his mouth, but this morning his skin is falling off!” She then dissolved into floods of tears.
 
The Paediatrician took one look at the blisters and broken skin around the baby’s umbilicus and nappy area and asked “could he have been scalded with hot water at all? He looks burnt!